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'Wdh�PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'0 FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /J r G / - CRY/ZIP <br /> CROSS STREET 1-711'��L��/1� / APN 04-7- 2-&V-07 PARCEL SIZ ' LAND USE APPLICATION# <br /> OWNER NAME C�/fi!/ /G` ��rrt Y��G z4 PHONE <br /> OWNERADDRESS `� CITY/STATE/ZIP <br /> CONTRACTOR / �� ��/ C7!- 5��. /!�• / - PH <br /> L-,ri <br /> / r <br /> CONTRACTOR ADDRESS Ft; � / CITV/STATE/ZIP <br /> SUBCONTRACTOR t�l/t-//'-- /� PHONE <br /> - SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,�c.rv57 ❑C-61 ❑D-09 ❑Gthtt NUMBE4-, / EXPIRATION DATE �^ / <br /> GEOGRAPHICAL INFORMATION! Coordinates X Y Township Range Section_ <br /> INTENDED USE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitonng ❑Soil Sampling/Chamcteriution <br /> ❑Public Water System <br /> Vdilf r f—Owner: arm ye.. ame .— .mea one um r <br /> TYPE OF WORK IfNew Well ❑Replacement Well ❑Well Alterstion/Modification ❑Omer <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) u of boong. ❑Geotechnical w afbonngr <br /> ❑Out-04-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Purrip ❑Pump Replacement ❑Pump Repair <br /> W ELL CONSTRUCTION <br /> Drilling Method>5Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> n_ � <br /> Proposed Well Depth !k ft Excavation / �� in diameter ❑Open Bottom ,Gravel Pack/Gravel Siu,� in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Cuing Diameter in Thickness/Gauge/ASTM Sched ❑Steel Mastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /_ R ❑Neat Cement(94 1b hag/J-10 gal water) -Sand Cement �✓• .rack mix/7 gal water <br /> ❑Bentonite(200/6 solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method dumped ❑Free Fell ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe } <br /> PUMP &Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R hl <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ' Iy11NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS U <br /> - SIGNED ./ �'- _ TITLE l ///"CF/ DATE 7-/-, <br /> (`t6 <br /> Icl'� <br /> lu- b <br /> I61 o <br /> VI <br /> �yb - <br /> 31�I- <br /> �� - <br /> 1 <br /> yD <br /> UI G <br /> _N IR <br /> / H <br /> DEPARTMENT USE ONLY C� <br /> ..L —/IL Date -7 1.5 U� Area Employee ID# s'j&�/ <br /> Application Accepted By y'C <br /> Grout Inspection I Date 0.^ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date �i-�'-'T' ❑ WAIVER Received <br /> Constructed Well Depth S� S It <br /> COMMENTSSCZEI�AJ 355'-a-75; �1-ltlV-41- &C 4 <br /> PE SC Received QjCtecAmount Date Permit/ Invoice# Well IDN <br /> Codes Info By Cash Remitted Service Request# <br /> 43 L-& I(ti o-7 us.0) o S (UO <br /> Lf-3.ro os a so oa 3 v 5 <br /> WELL PUMP PERMIT <br /> EHD 4M2-" <br /> IR7(2005 <br />